Development of a personalized bidirectional text messaging tool for HIV adherence assessment and intervention among substance abusers

Personalized interventions for behaviour change: A scoping review of just-in-time adaptive interventions

PURPOSE

Examine the development, implementation and evaluation of just-in-time adaptive interventions (JITAIs) in behaviour change and evaluate the quality of intervention reporting.

METHODS

A scoping review of JITAIs incorporating mobile health (mHealth) technologies to improve health-related behaviours in adults. We searched MEDLINE, Embase and PsycINFO using terms related to JITAIs, mHealth, behaviour change and intervention methodology. Narrative analysis assessed theoretical foundations, real-time data capturing and processing methods, outcome evaluation and summarized JITAI efficacy. Quality of intervention reporting was assessed using the template for intervention description and replication (TIDieR) checklist.

RESULTS

Sixty-two JITAIs across physical activity, sedentary behaviour, dietary behaviour, substance use, sexual behaviour, fluid intake, treatment adherence, social skills, gambling behaviour and self-management skills were included. The majority (71%) aimed to evaluate feasibility, acceptability and/or usability. Supporting evidence for JITAI development was identified in 46 studies, with 67% applying this to develop tailored intervention content. Over half (55%) relied solely on self-reported data for tailoring, and 13 studies used only passive monitoring data. While data processing methods were commonly reported, 44% did not specify their techniques. 89% of JITAI designs achieved full marks on the TIDieR checklist and provided sufficient details on JITAI components. Overall, JITAIs proved to be feasible, acceptable and user-friendly across behaviours and settings. Randomized trials showed tailored interventions were efficacious, though outcomes varied by behaviour.

CONCLUSIONS

JITAIs offer a promising approach to developing personalized interventions, with their potential effects continuously growing. The recommended checklist emphasizes the importance of reporting transparency in establishing robust intervention designs.

Smartphone Apps for Domestic Violence Prevention: A Systematic Review

Smartphone applications or apps are increasingly being produced to help with protection against the risk of domestic violence. There is a need to formally evaluate their features.

OBJECTIVE

This study systematically reviewed app-based interventions for domestic violence prevention, which will be helpful for app developers.

METHODS

We overviewed all apps concerning domestic violence awareness and prevention without language restrictions, collating information about features and limitations. We conducted searches in Google, the Google Play Store, and the App Store (iOS) covering a 10-year time period (2012-2022). We collected data related to the apps from the developers' descriptions, peer reviewed research articles, critical reviews in blogs, news articles, and other online sources.

RESULTS

The search identified 621 potentially relevant apps of which 136 were selected for review. There were five app categories: emergency assistance (n = 61, 44.9%), avoidance (n = 29, 21.3%), informative (n = 29, 21.3%), legal information (n = 10, 7.4%), and self-assessment (n = 7, 5.1%). Over half the apps (n = 97, 71%) were released in 2020-22. Around a half were from north-east America (n = 63, 46.3%). Where emergency alerts existed, they required triggering by the potential victim. There was no automation. Content analysis showed 20 apps with unique features, including geo-fences, accelerometer-based alert, shake-based alert, functionality under low resources, alert auto-cancellation, anonymous communication, and data encryption. None of the apps deployed artificial intelligence to assist the potential victims.

CONCLUSIONS

Apps currently have many limitations. Future apps should focus on automation, making better use of artificial intelligence deploying multimedia (voice, video, image capture, text and sentiment analysis), speech recognition, and pitch detection to aid in live analysis of the situation and for accurately generating emergency alerts.

More than just Reminders: Using text Messaging to Improve HIV care Outcomes Among Youth and Young Adults Living with HIV

This study evaluated engagement, satisfaction, and efficacy of an automated and live two-way text messaging intervention that linked youth and young adults at high risk for poor HIV outcomes to their medical case managers, with the aims of increasing viral load suppression rates and improving medical visit attendance. Participants (N = 100) were an average age of 22-23 years old. Most were Black (93%) and men who have sex with men (82%). A total of 89,681 automated text messages were sent to participants; and 62% of participants engaged in monthly text-message exchanges with medical case managers. McNemar's test results indicated that a significantly greater proportion of intervention participants were virally suppressed at 6 and 12 month follow-up than at enrollment. Adjusted odds ratio results showed a significant association between likelihood of achieving viral suppression at 6 and 12 months, and a greater number of participant responses to automated text messages. Future research should prospectively compare outcomes between usual care case management and usual care plus text-messaging to test for significant differences between groups.

Technology-mediated just-in-time adaptive interventions (JITAIs) to reduce harmful substance use: a systematic review

BACKGROUND AND AIMS

Lapse risk when trying to stop or reduce harmful substance use is idiosyncratic, dynamic and multi-factorial. Just-in-time adaptive interventions (JITAIs) aim to deliver tailored support at moments of need or opportunity. We aimed to synthesize evidence on decision points, tailoring variables, intervention options, decision rules, study designs, user engagement and effectiveness of technology-mediated JITAIs for reducing harmful substance use.

METHODS

Systematic review of empirical studies of any design with a narrative synthesis. We searched Ovid MEDLINE, Embase, PsycINFO, Web of Science, the ACM Digital Library, the IEEE Digital Library, ClinicalTrials.gov, the ISRCTN register and dblp using terms related to substance use/mHealth/JITAIs. Outcomes were user engagement and intervention effectiveness. Study quality was assessed with the mHealth Evidence Reporting and Assessment checklist.

FINDINGS

We included 17 reports of 14 unique studies, including two randomized controlled trials. JITAIs targeted alcohol (S = 7, n = 120 520), tobacco (S = 4, n = 187), cannabis (S = 2, n = 97) and a combination of alcohol and illicit substance use (S = 1, n = 63), and primarily relied on active measurement and static (i.e. time-invariant) decision rules to deliver support tailored to micro-scale changes in mood or urges. Two studies used data from prior participants and four drew upon theory to devise decision rules. Engagement with available JITAIs was moderate-to-high and evidence of effectiveness was mixed. Due to substantial heterogeneity in study designs and outcome variables assessed, no meta-analysis was performed. Many studies reported insufficient detail on JITAI infrastructure, content, development costs and data security.

CONCLUSIONS

Current implementations of just-in-time adaptive interventions (JITAIs) for reducing harmful substance use rely on active measurement and static decision rules to deliver support tailored to micro-scale changes in mood or urges. Studies on JITAI effectiveness are lacking.

A skills-based sero-status HIV disclosure intervention for sexual minority men in South Africa: A protocol for intervention adaptation and pilot randomized controlled trial (Preprint)

Background

Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV have low antiretroviral treatment adherence in South Africa due to limited skills in managing disclosure and prevention behaviors with sexual and romantic partners. As a result, there is a high HIV transmission risk within HIV-discordant partnerships, but an existing intervention may address these outcomes, if adapted effectively. Healthy Relationships (HR) is a behavioral intervention that was originally delivered in groups and in person over 5 sessions to develop coping skills for managing HIV-related stress and sexually risky situations, enhance decision-making skills for HIV disclosure to partners, and establish and maintain safer sex practices with partners. HR effectively improves prevention behaviors but has yet to be tailored to a non-US context.

Objective

We aim to adapt HR into a new culturally grounded intervention entitled Speaking Out & Allying Relationships for GBMSM and then assess its feasibility in Eastern Cape, South Africa.

Methods

The study will have 2 aims. For aim 1—adaptation—we will use a human-centered design approach. Initial intervention tailoring will involve integrating Undetectable=Untransmittable and pre-exposure prophylaxis education, developing intervention content for a videoconference format, and designing role-plays and movies for skill building based on preliminary data. Afterward, interviews and surveys will be administered to GBMSM to assess intervention preferences, and a focus group will be conducted with health care providers and information technology experts to assess the intervention’s design. Finally, a usability test will be performed to determine functionality and content understanding. Participants will be GBMSM living with HIV (n=15) who are in a relationship and health care providers and information technology (n=7) experts working in HIV care and programming with this population. For aim 2, we will examine the feasibility of the adapted intervention by using a pilot randomized control design. There will be 60 individuals per arm. Feasibility surveys and interviews will be conducted with the intervention arm, and behavioral and biomedical assessments for relationship and treatment adherence outcomes will be collected for both arms. All participants will be GBMSM living with HIV who are in a relationship with an HIV-negative or unknown status partner.

Results

Intervention adaptation began in August 2021. Initial tailoring and the refining of GBMSM intervention preferences were completed in December 2021. Usability and feasibility assessments are due to be completed by March 2022 and February 2024, respectively.

Conclusions

GBMSM need efficacious interventions that tackle partnership dynamics, HIV prevention, and treatment outcomes for antiretroviral treatment adherence and viral suppression in South Africa. Harnessing everyday technology use for social networking (eg, videoconferences), Undetectable=Untransmittable education, and pre-exposure prophylaxis to update an existing intervention for South African GBMSM has the potential to strengthen relationship communication about HIV treatment and prevention and, in turn, improve outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36845

Mobile phone and internet use among people who inject drugs: Implications for mobile health interventions

Background: Mobile health (mHealth) interventions have the potential to improve substance use treatment engagement and outcomes, and to reduce risk behaviors among people who inject drugs (PWID). However, there are few studies assessing mobile technology use among PWID and none have investigated continuity of mobile phone use. Methods: We surveyed 494 PWID. We used bivariate (independent-sample t- and chi-square tests) and multivariate (logistic regression) analyses to determine whether mobile phone and/or internet use differed as a function of participant- and/or injection-related characteristics. Results: Most participants (77%) had a mobile phone, with 67% having a phone that was free of charge. Participants with a phone were significantly less likely to be homeless (AOR = 0.28), to have shared syringes (AOR = 0.53), and to have reused syringes (AOR = 0.26) in the past 3 months. We observed high rates of phone and number turnover, with more than half reporting that they got a new phone (57%) and/or number (56%) at least once within the past 3 months. Most participants were familiar with using the internet (80% ever use), though participants who had ever used the internet were younger (AOR = 0.89), were less likely to be homeless (AOR = 0.38), were less likely to have shared syringes (AOR = 0.49), and were more likely to have injected methamphetamine by itself (AOR = 2.49) in the past 3 months. Conclusions: Overall, mobile technology and internet use was high among our sample of PWID. Several factors should be considered in recruiting diverse samples of PWID to minimize bias in mHealth study outcomes, including mobile phone access and protocol type (text- vs internet-based).

Text Messaging Improves HIV Care Continuum Outcomes Among Young Adult Trans Women Living with HIV: Text Me, Girl!

Young adult trans women living with HIV in the US exhibit suboptimal advancement through the HIV Care Continuum relative to national averages. From December 2016 through May 2018, 134 young adult trans women living with HIV enrolled in Text Me, Girl!, a theory-based, trans-specific text-messaging intervention designed to improve HIV Care Continuum outcomes. Participants (N = 130) averaged 29.5 years, were predominantly Latinx (43%) or African American/Black (40%). Clustered logistic and ordinal logistic multivariable models (n = 105; 366 observations) indicate that through 18-month follow-up, increased exposure to the text-messaging intervention was associated with significant (p < 0.05) increased retention to HIV care (adjusted odds ratio [aOR] 1.33) and biomarker-confirmed viral suppression (aOR 1.51); retention in the intervention was associated with significantly increased likelihood of ART uptake (aOR 2.95) and "excellent" ART adherence (aOR 10.44). Text Me, Girl! offers promising evidence that a unidirectional, automated text-messaging intervention can improve HIV care outcomes among young adult trans women living with HIV.

Elevated Perceived Risk for HIV as a Barrier to Accessing Health Care Among Black Men Who Have Sex with Men

We sought to examine how self-perception of risk for HIV and HIV status information avoidance are related to HIV testing uptake and engagement in routine health care among Black men who have sex with men (BMSM)-the group at highest risk for HIV in the USA. To do so, we used generalized linear modeling and serial mediation modeling to assess data from 342 HIV-negative BMSM collected from 2017 to 2019 in Atlanta, GA, USA. Participants reported considerable concern for testing HIV-positive; 40% reported believing they would test positive for HIV; 27% reported being "extremely concerned about getting HIV"; and 17% reported worrying about HIV "all the time". Mediation analyses demonstrated that greater concern for HIV was associated with longer intervals since the last HIV test and the last health-care appointment. BMSM perceived themselves to be at considerable risk for HIV, but critically, this outlook did not yield improved health-care behaviors. Findings highlight the need to reconceptualize our public health approach to reaching BMSM. Emphasizing risk behavior and targeting efforts toward BMSM may have unintended consequences and need to be reevaluated. Despite continued efforts to improve HIV-related outcomes, we are failing to meet the needs of BMSM.

A mobile health intervention in HIV primary care: supporting patients at risk for ART non-adherence

Mobile health (mHealth) interventions that are integrated in HIV clinical settings to facilitate ongoing patient-provider communication between primary care visits are garnering evidence for their potential in improving HIV outcomes. Rango is an mHealth intervention to support engagement in HIV care and treatment adherence. This study used a single-arm prospective design with baseline and 6-month assessments for pre-post comparisons, as well as a matched patient sample for between-group comparisons to test Rango's preliminary efficacy in increasing viral suppression. The Rango sample (n = 406) was predominantly 50 years of age or older (63%; M = 50.67; SD = 10.97, 23-82), Black/African-American (44%) or Hispanic/Latinx (38%), and male (59%). At baseline, 18% reported missing at least one dose of ART in the prior three days and chart reviews of recent VL showed that nearly 82% of participants were virally suppressed. Overall 95% of the patients enrolled in Rango returned for a medical follow-up visit. Of the 65 unsuppressed patients at baseline who returned for a medical visit, 38 (59%) achieved viral suppression and only 5% of the suppressed group at baseline had an increase in viral load at 6 months despite being at risk for ART non-adherence. While viral suppression was similar between Rango participants and patients receiving treatment as usual over the same time period, it is unknown whether those patients were similarly at risk for non-adherence. Our findings support efforts to formally test this innovative approach in addressing ART non-adherence and viral suppression particularly to reach HIV treatment goals.

Do interventions to improve adherence to antiretroviral therapy recognise diversity? A systematic review

People living with HIV (PLWH) are often culturally and linguistically diverse populations; these differences are associated with differing barriers to antiretroviral therapy (ART) adherence. Cultural competence measures the extent to which trial design recognises this diversity. This systematic review aimed to determine whether adherence trial participants represent the diversity of PLWH. Randomised Controlled Trials in Organisation for Economic Co-operation and Development countries to improve ART adherence were eligible. We searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews. For all included trials, we searched for their development, testing and evaluation studies. We compared trial participant characteristics with nationally reported PLWH data. We appraised trial cultural competence against ten criteria; scoring each criterion as 0, 1 or 2 indicating cultural blindness, pre-competence or competence respectively. For 80 included trials, a further 13 studies presenting development/testing/evaluation data for the included trials were identified. Only one of the 80 included studies reported trial participants representative of the country's population of PLWH. The median (IQ) cultural competence score was 2.5 (1.0, 4.0) out of 20. HIV adherence trial participants are not reflective of the population with HIV, which may be due to limited adoption of culturally competent research methods.

The Implementation of a Text Messaging Intervention to Improve HIV Continuum of Care Outcomes Among Persons Recently Released From Correctional Facilities: Randomized Controlled Trial

Background

Previously incarcerated individuals have suboptimal linkage and engagement in community HIV care. Mobile health (mHealth) interventions have been shown to be effective in addressing these gaps. In Washington, District of Columbia (DC), we conducted a randomized trial of an SMS text messaging–based mHealth intervention (CARE+ Corrections) to increase linkage to community HIV care and antiretroviral treatment adherence among HIV-infected persons involved in the criminal justice system.

Objective

This study aimed to describe the SMS text messaging–based intervention, participant use of the intervention, and barriers and facilitators of implementation.

Methods

From August 2013 to April 2015, HIV-positive incarcerated individuals were recruited within the DC Department of Corrections, and persons released in the past 6 months were recruited within the community via street-based recruitment, community partnerships, and referrals. Participants were followed for 6 months and received weekly or daily SMS text messages. Formative research resulted in the development of the content of the messages in 4 categories: HIV Appointment Reminders, Medication Adherence, Prevention Reminders, and Barriers to Care following release from jail. Participants could customize the timing, frequency, and message content throughout the study period.

Results

Of the 112 participants enrolled, 57 (50.9%) were randomized to the intervention group and 55 (49.1%) to the control group; 2 control participants did not complete the baseline visit, and were dropped from the study, leaving a total of 110 participants who contributed to the analyses. Study retention was similar across both study arms. Median age was 42 years (IQR 30-50), 86% (49/57) were black or African American, 58% (33/57) were male, 25% (14/57) were female, and 18% (10/57) were transgender. Median length of last incarceration was 4 months (IQR 1.7-9.0), and median lifetime number of times incarcerated was 6.5 (IQR 3.5-14.0). Most participants (32/54, 59%) had a baseline viral load of <200 copies/mL. Nearly all participants (52/57, 91%) chose to use a cell phone provided by the study. The most preferred Appointment Reminder message was Hey how you feeling? Don’t forget to give a call and make your appointment (19/57, 33%). The most preferred Medication Adherence message was Don’t forget your skittles! (31/57, 54%), and 63% (36/57) of participants chose to receive daily (vs weekly) messages from this category at baseline. The most preferred Prevention Reminder message was Stay strong. Stay clean (18/57, 32%). The most preferred Barriers to Care message was Holla at your case manager, they’re here to help (12/57, 22%). Minor message preference differences were observed among participants enrolled in the jail versus those from the community.

Conclusions

Participants’ ability to customize their SMS text message plan proved helpful. Further large-scale research on mHealth platforms is needed to assess its efficacy among HIV-infected persons with a history of incarceration.

Trial Registration

ClinicalTrials.gov NCT01721226; https://clinicaltrials.gov/ct2/show/NCT01721226

A novel technology-enhanced internalized stigma and shame intervention for HIV-positive persons with substance use disorders

Internalized stigma, shame, and other negative self-conscious emotions are inadequately addressed barriers to HIV-related self-care, particularly among people actively using substances. Innovative approaches are needed to optimize antiretroviral treatment (ART) adherence as well as engagement in HIV care among people living with HIV and substance use disorders. Based on qualitative feedback from providers and patients, we iteratively developed and conducted a proof-of-concept study of a relatively brief transdiagnostic emotion regulation intervention designed to improve ART adherence care by addressing behavioral and psychological barriers, including internalized stigma and shame, among people living with HIV and active substance use disorders. The final intervention included 5 individual sessions focused on metacognitive awareness of emotions and thoughts, cognitive reframing of dysfunctional thoughts about the self using concepts such as self-compassion, and identifying and reaching the participants' personalized HIV-self-care goal(s). All participants received daily texts querying current emotion and weekly texts querying ART adherence and substance use. To extend the effects of the intervention, we developed a personalized bi-directional text component through which participants received their personalized compassionate self-statements, informed by the intervention content, in response to their answers to emotion queries for 8 weeks after the 5 sessions. The texts modeled using compassionate self-statements as a form of cognitive reframing, consistent with cognitive restructuring of distorted core beliefs. We consented 10 participants living with HIV and problematic substance use in the proof-of-concept pilot. Of the 8 participants who completed all intervention sessions, participants replied to 70% of all text messages sent. All 8 reported strong acceptability of the intervention content. This emotion-focused, technology-enhanced intervention demonstrated proof-of-concept, in that this patient population would participate in this intervention. A larger randomized controlled pilot is needed to determine feasibility and acceptability among people living with HIV and substance use disorders, a hard-to-reach and underserved population.

A Randomized Controlled Trial of a Text Messaging Intervention to Promote Virologic Suppression and Retention in Care in an Urban Safety-Net Human Immunodeficiency Virus Clinic: The Connect4Care Trial

Background

Text messaging is a promising strategy to support human immunodeficiency virus (HIV) care engagement, but little is known about its efficacy in urban safety-net HIV clinics.

Methods

We conducted a randomized controlled trial of a supportive and motivational text messaging intervention, Connect4Care (C4C), among viremic patients who had a history of poor retention or were new to the clinic. Participants were randomized (stratified by new or established HIV diagnosis status) to receive either of the following for 12 months: (1) thrice-weekly intervention messages, plus texted primary care appointment reminders and a monthly text message requesting confirmation of study participation or (2) texted reminders and monthly messages alone. Viral load was assessed at 6 and 12 months. The primary outcome was virologic suppression (<200 copies/mL) at 12 months, estimated via repeated-measures log-binomial regression, adjusted for new-diagnosis status. The secondary outcome was retention in clinic care.

Results

Between August 2013 and November 2015, a total of 230 participants were randomized. Virologic suppression at 12 months was similar in intervention and control participants (48.8% vs 45.8%, respectively), yielding a rate ratio of 1.07 (95% confidence interval, .82-1.39). Suppression was higher in those with newly diagnosed infection (78.3% vs 45.3%). There were no intervention effects on the secondary outcome. Exploratory analyses suggested that patients with more responses to study text messages had better outcomes, regardless of arm.

Conclusions

The C4C text messaging intervention did not significantly increase virologic suppression or retention in care. Response to text messages may be a useful way for providers to gauge risk for poor HIV outcomes.

Clinical Trials Registration

NCT01917994.

Design, validation and testing of short text messages for an HIV mobile-health intervention to improve antiretroviral treatment adherence in Mexico

Mobile Health (mHealth) interventions have become effective strategies to increase adherence to antiretroviral treatment (ART) in people living with HIV (PLWH). mHealth interventions use phone calls, e-mails, smartphone apps or short text messages (SMS) as reminders of medical appointments or ART adherence. SMS are a highly accepted mHealth strategy. Systematized processes to validate SMS tailored to end-user preferences are required to increase the effectiveness of mHealth interventions. We describe a structured approach to develop a set of SMS tailored to Mexican HIV+ individuals, focused on improving ART adherence and healthcare appointments. The process included three sequential phases: SMS design by HIV-healthcare professionals, validation by expert referees, and testing by PLWH. A set of 108 SMS in four categories (motivational self-healthcare messages, ART-collection, medical and laboratory-appointment reminders) was designed. Expert referees assessed 94.5% of messages as adequate, 65.7% as useful. Seventy-one SMS were further tested by PLWH, who considered 100% of SMS to be understandable and 57.7% useful. SMS had adequate intra-judge agreement scores for clarity and acceptability (ICC-2 = .08-.49). Qualitative feedback from expert referees and PLWH was incorporated into SMS. A final set of 41 highest-rated SMS was obtained. Careful validation of SMS could increase the effectiveness of mHealth interventions.

Content guidance for mobile phones short message service (SMS)-based antiretroviral therapy adherence and appointment reminders: a review of the literature

Mobile phones are increasingly being used to support health activities, including the care and management of people living with HIV/AIDS. Short message service (SMS) has been explored as a means to optimize and support behaviour change. However, there is minimal guidance on messaging content development. The purpose of this review was to inform the content of SMS messages for mobile health (mHealth) initiatives designed to support anti-retroviral therapy adherence and clinic appointment keeping in resource-limited settings. PubMed, OvidMedline, Google Scholar, K4Health's mHealth Evidence database, the mHealth Working Group project resource, and Health COMpass were searched. A request to online communities for recommendations on message content was also made. 1010 unique sources were identified, of which 51 were included. The information was organized into three categories: pre-message development, message development, and security and privacy. Fifteen of the publications explicitly provided their message content. Important lessons when developing the content of SMS were: (1) conducting formative research; (2) grounding content in behaviour change theory; and (3) reviewing proposed content with experts. Best practices exist for developing message content for behaviour change. Efforts should be continued to apply lessons learned from the existing literature to inform mHealth initiatives supporting HIV/AIDS care and treatment.

Development of PositiveLinks: A Mobile Phone App to Promote Linkage and Retention in Care for People With HIV

Background

Linkage to and retention in HIV care are challenging, especially in the Southeastern United States. The rise in mobile phone app use and the potential for an app to deliver just in time messaging provides a new opportunity to improve linkage and retention among people living with HIV (PLWH).

Objective

This study aimed to develop an app to engage, link, and retain people in care. We evaluated the acceptability, feasibility, and impact of the app among users.

Methods

App development was informed by principles of chronic disease self-management and formative interviews with PLWH. Once developed, the app was distributed among participants, and usability feedback was incorporated in subsequent iterations. We interviewed app users after 3 weeks to identify usability issues, need for training on the phone or app, and to assess acceptability. We tracked and analyzed usage of app features for the cohort over 2 years.

Results

A total of 77 participants used the app during the pilot study. The query response rate for the first 2 years was 47.7%. Query response declined at a rate of 0.67% per month. The community message board was the most popular feature, and 77.9% (60/77) of users posted on the board at least once during the 2 years.

Conclusions

The PositiveLinks app was feasible and acceptable among nonurban PLWH. High participation on the community message board suggests that social support from peers is important for people recently diagnosed with or returning to care for HIV.

Mining User-Generated Content in an Online Smoking Cessation Community to Identify Smoking Status: A Machine Learning Approach

Online smoking cessation communities help hundreds of thousands of smokers quit smoking and stay abstinent each year. Content shared by users of such communities may contain important information that could enable more effective and personally tailored cessation treatment recommendations. This study demonstrates a novel approach to determine individuals' smoking status by applying machine learning techniques to classify user-generated content in an online cessation community. Study data were from BecomeAnEX.org, a large, online smoking cessation community. We extracted three types of novel features from a post: domain-specific features, author-based features, and thread-based features. These features helped to improve the smoking status identification (quit vs. not) performance by 9.7% compared to using only text features of a post's content. In other words, knowledge from domain experts, data regarding the post author's patterns of online engagement, and other community member reactions to the post can help to determine the focal post author's smoking status, over and above the actual content of a focal post. We demonstrated that machine learning methods can be applied to user-generated data from online cessation communities to validly and reliably discern important user characteristics, which could aid decision support on intervention tailoring.

Adaptive Antiretroviral Therapy Adherence Interventions for Youth Living With HIV Through Text Message and Cell Phone Support With and Without Incentives: Protocol for a Sequential Multiple Assignment Randomized Trial (SMART)

BACKGROUND

Youth living with HIV (YLH) aged 13 to 24 years made up over a fifth (21%) of new HIV diagnoses in 2016, yet only 27% of YLH are virally suppressed. YLH have been shown to be poorly adherent to antiretroviral therapy (ART); however, there has been limited research investigating how to increase adherence in YLH. Mobile health (mHealth) interventions may be one promising way to do this.

OBJECTIVE

This study (ATN [Adolescent Trials Network] 144 SMART) aimed to compare adaptive interventions that could increase ART adherence in YLH aged 15 to 24 years. This includes mHealth initiatives, the tapering of interventions, and the use of incentives. Cost-effectiveness of sequencing the interventions without incentives before providing incentives and the savings on societal costs due to suppressed viral loads will be determined. This protocol is part of the ATN Scale It Up program described in this issue by Naar et al.

METHODS

This study uses a Sequential Multiple Assignment Randomized Trial design. Approximately 190 participants are being recruited, enrolled, and randomized to either cell phone support or text message support. Both intervention groups receive 3 months of intervention, followed by a second randomization based on response to the intervention. Responders test tapering their intervention, and nonresponders test receiving incentives.

RESULTS

Data collection for this study is projected to begin in August 2018 and last until June 2020.

CONCLUSIONS

This is an innovative study, particularly in terms of population, intervention types, focus on cost-effectiveness, and recruitment. This study could be particularly effective in improving adherence in YLH while reducing long-term individual and societal costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03535337; https://clinicaltrials.gov/ct2/show/NCT03535337 (Archived by WebCite at http://www.webcitation.org/74alXb92z).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/11183.

Addressing Stigma Through a Virtual Community for People Living with HIV: A Mixed Methods Study of the PositiveLinks Mobile Health Intervention

Stigma has negative consequences for quality of life and HIV care outcomes. PositiveLinks is a mobile health intervention that includes a secure anonymous community message board (CMB). We investigated discussion of stigma and changes in stigma scores. Of 77 participants in our pilot, 63% were male, 49% Black, and 72% had incomes below the federal poverty level. Twenty-one percent of CMB posts (394/1834) contained stigma-related content including negative (experiencing stigma) and positive (overcoming stigma) posts addressing intrapersonal and interpersonal stigma. Higher baseline stigma was positively correlated with stress and negatively correlated with HIV care self-efficacy. 12-month data showed a trend toward more improved stigma scores for posters on the CMB versus non-posters (- 4.5 vs - 0.63) and for posters of stigma-related content versus other content (- 5.1 vs - 3.3). Preliminary evidence suggests that a supportive virtual community, accessed through a clinic-affiliated smartphone app, can help people living with HIV to address stigma.

Substance Use and Adherence to Antiretroviral Therapy: What Is Known and What Is Unknown

PURPOSE OF REVIEW

People who use drugs face multiple challenges to achieve optimal HIV treatment outcomes. This review discusses the current knowledge in substance use and antiretroviral therapy adherence, highlighting recent findings and potential interventions.

RECENT FINDINGS

Studies continue to demonstrate the negative impacts of substance use and related disorders on antiretroviral therapy adherence, with the exception of cannabis. Evidence-based addiction treatment, in particular, opioid agonist therapy, appears to improve adherence levels. Most individual-level adherence specific interventions did not provide sustained effects, and no studies evaluating structural-level interventions were found. Findings suggest the urgent need to scale-up opioid agonist therapy, as well as to simultaneously address multiple structural barriers to care to optimize HIV treatment outcomes among people who use drugs.

PositiveLinks: A Mobile Health Intervention for Retention in HIV Care and Clinical Outcomes with 12-Month Follow-Up

Mobile health interventions may help People Living with HIV (PLWH) improve engagement in care. We designed and piloted PositiveLinks, a clinic-affiliated mobile intervention for PLWH, and assessed longitudinal impact on retention in care and viral suppression. The program was based at an academic Ryan White Clinic serving a nonurban population in Central Virginia. The PL intervention included a smartphone app that connected participants to clinic staff and provided educational resources, daily queries of stress, mood and medication adherence, weekly quizzes, appointment reminders, and a virtual support group. Outcomes were analyzed using McNemar's tests for HRSA-1, visit constancy, and viral suppression and nonparametric Wilcoxon signed-rank tests for CD4 counts and viral loads. Of 77 participants, 63% were male, 49% black non-Hispanic, and 72% below the federal poverty level. Participants' achievement of a retention in care benchmark (HRSA-1) increased from 51% at baseline to 88% at 6 months (p < 0.0001) and 81% at 12 months (p = 0.0003). Visit constancy improved from baseline to 6 months (p = 0.016) and 12 months (p = 0.0004). Participants' mean CD4 counts increased from baseline to 6 months (p = 0.0007) and 12 months (p = 0.0005). The percentage of participants with suppressed viral loads increased from 47% at baseline to 87% at 6 months (p < 0.0001) and 79% at 12 months (p = 0.0007). This study is one of the first to demonstrate that a mobile health intervention can have a positive impact on retention in care and clinical outcomes for vulnerable PLWH. Next steps include integration with clinical practice and dissemination.

A Community-Based Addiction Rehabilitation Electronic System to Improve Treatment Outcomes in Drug Abusers: Protocol for a Randomized Controlled Trial

Introduction: Relapse is very common in drug abusers and contributes to a series of negative consequences. Effective addiction treatment exists but there are some problems in the implementation process. Mobile health (mHealth) offers a potential solution to improving recovery outcome for drug abusers in the community. The research team developed a community-based addiction rehabilitation electronic system (CAREs). The primary aim of this study is to explore whether the integrated rehabilitation based on program CAREs promotes drug abusers to keep abstinence. The secondary aim is to evaluate the impact of CAREs on interaction between drug users and service providers, and on addiction-related physical and social functions. Method and analysis: A randomized controlled trial (RCT) will be conducted. The study is a superiority trial with parallel group design. Seventy drug abusers who are newly ordered to undergo community rehabilitation will be recruited from the community in Shanghai. Participants will be 1:1 randomly assigned to receive integrated community rehabilitation by using CAREs or only receiving routine community rehabilitation for 6 months. Corresponding social workers will provide service and monitor their drug use behavior in accordance with the routine work-flow. Outcomes will be assessed at baseline and in the 6th month. The primary outcome is the performance on illicit drug urine test which will be carried out regularly twice per week during the study period. Secondary study outcomes include longest duration of sustained abstinence, days that participants interact with social workers, and the decrease rate of addiction-related issues severity index. Chi-square tests and ANOVAs will be used to compare characteristics of the members of the two groups. GEE will be used to compare the seven dimensions scores of the ASI between groups. Discussion: The study provides evidence for the feasibility and effectiveness of the "CAREs" system through comparing the results of the intervention group with the control group. This paper describes the design and methodology of the study. Ethics and dissemination: The Ethical Board of SMHC approved the study protocol. All participants will present for the informed consent process. After study completion, the results will be published. Trial Registration: ClinicalTrials.gov NCT03451344, https://clinicaltrials.gov/ct2/show/NCT03451344.

mHealth Interventions To Support Self-Management In HIV: A Systematic Review

Background:

Self-management is an important aspect of long-term HIV treatment. Mobile technologies offer the potential to efficiently deliver interventions to facilitate HIV self-management. The last comprehensive review of such mHealth interventions was conducted in 2011. Given the rapidly evolving field, a need was identified for an updated review of the literature.

Objective:

The study aimed to describe and evaluate current evidence-based mHealth interventions to support self-management in HIV.

Method:

Eight online databases (Medline, Scopus, Embase, PsycINFO, Cochrane, Global Health CAB, IEEE explore, Web of Science) were systematically searched for papers describing and evaluating mHealth HIV self-management interventions. Reference lists of relevant papers were also searched. Data on intervention content and evaluation methodology were extracted and appraised by two researchers.

Results:

41 papers were identified evaluating 28 interventions. The majority of these interventions (n=20, 71%) had a single focus of either improving adherence (n=16), increasing engagement in care (n=3) or supporting smoking cessation (n=1), while just 8 (29%) were more complex self-management interventions, targeting a range of health-related behaviours. Interventions were predominantly delivered through SMS messaging. They significantly impacted on a range of outcomes including adherence, viral load, mental health and social support.

Conclusion:

Since the last major review of mHealth interventions in HIV, there has been a shift from exploratory acceptability/feasibility studies to impact evaluations. While overall the interventions impacted on a range of outcomes, they were generally limited in scope, failing to encompass many functions identified as desirable by people living with HIV. Participant incentives may limit the generalizability of findings.

Lessons Learned From the Implementation of Seek, Test, Treat, Retain Interventions Using Mobile Phones and Text Messaging to Improve Engagement in HIV Care for Vulnerable Populations in the United States

In the United States, little is known about interventions that rely on mobile phones and/or text messaging to improve engagement in HIV care for vulnerable populations. Domestic studies using these technologies as part of the National Institute on Drug Abuse "Seek, Test, Treat, Retain" research initiative were queried regarding intervention components, implementation issues, participant characteristics, and descriptive statistics of mobile phone service delivery. Across five studies with 1,135 predominantly male, minority participants, implementation challenges occurred in three categories: (1) service interruptions; (2) billing/overage issues, and; (3) the participant user experience. Response rules for automated text messages frequently frustrated participants. The inability to reload minutes/texting capacity remotely was a significant barrier to intervention delivery. No study encountered confidentiality breaches. Service interruption was common, even if studies provided mobile phones and plans. Future studies should attend to the type of mobile phone and service, the participant user experience, and human subjects concerns.

Text message reminders for improving patient appointment adherence in an office-based buprenorphine program: A feasibility study

BACKGROUND AND OBJECTIVES

Missed visits are common in office-based buprenorphine treatment (OBOT). The feasibility of text message (TM) appointment reminders among OBOT patients is unknown.

METHODS

This 6-month prospective cohort study provided TM reminders to OBOT program patients (N = 93). A feasibility survey was completed following delivery of TM reminders and at 6 months.

RESULTS

Respondents reported that the reminders should be provided to all OBOT patients (100%) and helped them to adhere to their scheduled appointment (97%). At 6 months, there were no reports of intrusion to their privacy or disruption of daily activities due to the TM reminders. Most participants reported that the TM reminders were helpful in adhering to scheduled appointments (95%), that the reminders should be offered to all clinic patients (95%), and favored receiving only TM reminders rather than telephone reminders (95%). Barriers to adhering to scheduled appointment times included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic wait-times (9%), being hospitalized or sick (8%), feeling sad or depressed (6%), and child care (6%).

CONCLUSIONS

This study demonstrated the acceptability and feasibility of TM appointment reminders in OBOT. Older age and longer duration in buprenorphine treatment did not diminish interest in receiving the TM intervention. Although OBOT patients expressed concern regarding the privacy of TM content sent from their providers, privacy issues were uncommon among this cohort. Scientific Significance Findings from this study highlighted patient barriers to adherence to scheduled appointments. These barriers included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic lines (9%), and other factors that may confound the effect of future TM appointment reminder interventions. Further research is also required to assess 1) the level of system changes required to integrate TM appointment reminder tools with already existing electronic medical records and appointment records software; 2) acceptability among clinicians and administrators; and 3) financial and resource constraints to healthcare systems. (Am J Addict 2017;26:581-586).

Efficacy of raltegravir, etravirine and darunavir/ritonavir for treatment-experienced HIV patients from a non-urban clinic population in the United States

BACKGROUND

The regimen of raltegravir (RAL), ritonavir-boosted darunavir (DAR/r), and etravirine (ETR) for HIV treatment-experienced patients in a non-clinical trial setting in the rural/semi-urban United States had not been evaluated.

OBJECTIVE

A retrospective cohort analysis was performed of adult patients prescribed the regimen from 2008 to 2013 at a HIV clinic serving such a population.

RESULTS

In all, 51 patients met inclusion criteria including 15 with suppressed viral loads at regimen initiation. Of the 36 patients with detectable viral loads, 22 (61.1%) achieved a plasma HIV-1 RNA level < 50 copies/ml at 28 weeks and 17 maintained viral suppression at 56 weeks (50% of those surviving without death). Of 42 patients with long-term follow-up, mean of 216 ± 83 weeks following regimen initiation, 31 (73.8%) had viral suppression. Suppression was significantly more likely in those patients that maintained adherence.

CONCLUSIONS

In a non-urban clinic population from the United States with considerable treatment experience, the combination of RAL, DAR/r, and ETR was well tolerated and resulted in viral suppression in those that maintained adherence. Future prospective studies may better define the role of such a regimen in the context of revised recommendations for first-line medications in the HIV treatment naïve.

Evidence for Technology Interventions to Promote ART Adherence in Adult Populations: a Review of the Literature 2012-2015

Leveraging technology to enhance antiretroviral therapy (ART) adherence, and factors associated with it, has tremendous appeal as a low-cost, generalizable strategy to offer high-quality adherence support given an increasingly limited workforce. As the numbers of individuals living with HIV entering care and initiating ART are expected to increase substantially worldwide in the next decade, capacity to support ART adherence is needed and use of computers, internet, and mobile phones has the potential to offer those efficiencies-provided they are effective. This review summarizes recent advances in the evidence base for technology-driven, technology-delivered, or technology-enhanced ART adherence intervention approaches. A PubMed search limited to January 2013 through July 2015 identified 13 qualifying studies evaluating computer-delivered interventions, internet approaches, mobile phone technologies, and electronic dose monitoring with triggered messaging and data-informed counseling. Considerable support for each area has emerged, with the majority of studies reviewed demonstrating significant effects on ART adherence and clinical outcomes. Gaps are identified and recommendations offered.

Feasibility and Acceptability of a Smartphone App for Daily Reports of Substance Use and Antiretroviral Therapy Adherence among HIV-Infected Adults

While substance use is one of the most consistent predictors of poor adherence to antiretroviral therapy (ART), few studies among people living with HIV (PLH) have utilized mobile phone-based assessment of these health behaviors. PLH were recruited from primary care clinics to report ART and substance use using a smartphone application (app) for 14 consecutive days. The app's feasibility as a data collection tool was evaluated quantitatively via surveys and qualitatively via in-depth interviews to assess daily report completion, compliance, and study satisfaction. Overall, 26 participants (M = 49.5 years, 76% male) completed 95.3% of time-based daily reports. Participants reported high satisfaction with the app and expressed future interest in using smartphones to report daily behaviors. High completion rates and participant acceptability suggest that smartphones are a feasible, acceptable method for collecting substance use and ART data among PLH. Potential areas of concern such as sufficient training and assistance for those with limited smartphone experience should be considered for future app-based research studies among PLH.

Pilot RCT of bidirectional text messaging for ART adherence among nonurban substance users with HIV

OBJECTIVE

This pilot study tested the preliminary efficacy of a theory-based bidirectional text messaging intervention (TEXT) on antiretroviral (ART) adherence, missed care visits, and substance use among people with HIV.

METHOD

Participants with recent substance use and ART nonadherence from 2 nonurban HIV clinics were randomized to TEXT or to usual care (UC). The TEXT intervention included daily queries of ART adherence, mood, and substance use. The system sent contingent intervention messages created by participants for reports of adherence/nonadherence, good mood/poor mood, and no substance use/use. Assessments were at preintervention, postintervention, and 3-month postintervention follow-up. Objective primary outcomes were adherence, measured by past 3-month pharmacy refill rate, and proportion of missed visits (PMV), measured by medical records. The rate of substance-using days from the timeline follow-back was a secondary outcome.

RESULTS

Sixty-three patients participated, with 33 randomized to TEXT and 30 to UC. At preintervention, adherence was 64.0%, PMV was 26.9%, and proportion of days using substances was 53.0%. At postintervention, adherence in the TEXT condition improved from 66% to 85%, compared with 62% to 71% in UC participants (p = .04). PMV improved from 23% to 9% for TEXT participants and 31% to 28% in UC participants (p = .12). There were no significant differences between conditions in substance-using days at postintervention. At 3-month follow-up, differences were not significant.

CONCLUSIONS

Personalized bidirectional text messaging improved adherence and shows promise to improve visit attendance, but did not reduce substance using days. This intervention merits further testing and may be cost-efficient given its automation.

Realising the technological promise of smartphones in addiction research and treatment: An ethical review

BACKGROUND

Smartphone technologies and mHealth applications (or apps) promise unprecedented scope for data collection, treatment intervention, and relapse prevention when used in the field of substance abuse and addiction. This potential also raises new ethical challenges that researchers, clinicians, and software developers must address.

AIMS

This paper aims to identify ethical issues in the current uses of smartphones in addiction research and treatment.

METHODS

A search of three databases (PubMed, Web of Science and PsycInfo) identified 33 studies involving smartphones or mHealth applications for use in the research and treatment of substance abuse and addiction. A content analysis was conducted to identify how smartphones are being used in these fields and to highlight the ethical issues raised by these studies.

RESULTS

Smartphones are being used to collect large amounts of sensitive information, including personal information, geo-location, physiological activity, self-reports of mood and cravings, and the consumption of illicit drugs, alcohol and nicotine. Given that detailed information is being collected about potentially illegal behaviour, we identified the following ethical considerations: protecting user privacy, maximising equity in access, ensuring informed consent, providing participants with adequate clinical resources, communicating clinically relevant results to individuals, and the urgent need to demonstrate evidence of safety and efficacy of the technologies.

CONCLUSIONS

mHealth technology offers the possibility to collect large amounts of valuable personal information that may enhance research and treatment of substance abuse and addiction. To realise this potential researchers, clinicians and app-developers must address these ethical concerns to maximise the benefits and minimise risks of harm to users.

Emerging Drug Use Trends in Kelantan, Malaysia

The primarily rural and agrarian Kelantan province of Malaysia has high rates of drug use and is characterized by unique sociocultural factors. Combining qualitative and ethnographic methods, we investigated drug use and treatment needs of people who use drugs (PWUD) in rural areas of Kelantan. In February 2014, field visits, participant observation, and focus group discussions (FGDs) with 27 active PWUD were conducted in rural areas surrounding the capital city of Kelantan. The findings indicate a high prevalence of opiate and amphetamine type stimulants (ATS) use in these areas. FGD participants reported initiating drug use at early ages due to peer influences, to relieve boredom, to cope with problems, and a high saturation of villages with other PWUD was reported as a major contributor to their own continued drug use. They reported a trend of drug use initiation at younger ages and increased drug use among females. Participants were interested in treatment; however, their limited knowledge about treatment options and perceived limited availability of services were barriers to treatment seeking. Easy access to drugs, primarily from Thailand and facilitated by the use of mobile phones, resulted in an expanding prevalence of drug use that underscores the need to bolster education and prevention efforts and accessibility of treatment services in Kelantan.

Factors associated with patterns of mobile technology use among persons who inject drugs

BACKGROUND

New and innovative methods of delivering interventions are needed to further reduce risky behaviors and increase overall health among persons who inject drugs (PWID). Mobile health (mHealth) interventions have potential for reaching PWID; however, little is known about mobile technology use (MTU) in this population. In this study, the authors identify patterns of MTU and identified factors associated with MTU among a cohort of PWID.

METHODS

Data were collected through a longitudinal cohort study examining drug use, risk behaviors, and health status among PWID in San Diego, California. Latent class analysis (LCA) was used to define patterns of MTU (i.e., making voice calls, text messaging, and mobile Internet access). Multinomial logistic regression was then used to identify demographic characteristics, risk behaviors, and health indicators associated with mobile technology use class.

RESULTS

In LCA, a 4-class solution fit the data best. Class 1 was defined by low MTU (22%, n = 100); class 2, by PWID who accessed the Internet using a mobile device but did not use voice or text messaging (20%, n = 95); class 3, by primarily voice, text, and connected Internet use (17%, n = 91); and class 4, by high MTU (41%, n = 175). Compared with low MTU, high MTU class members were more likely to be younger, have higher socioeconomic status, sell drugs, and inject methamphetamine daily.

CONCLUSION

The majority of PWID in San Diego use mobile technology for voice, text, and/or Internet access, indicating that rapid uptake of mHealth interventions may be possible in this population. However, low ownership and use of mobile technology among older and/or homeless individuals will need to be considered when implementing mHealth interventions among PWID.

Optimising text messaging to improve adherence to web-based smoking cessation treatment: a randomised control trial protocol

INTRODUCTION

Millions of smokers use the Internet for smoking cessation assistance each year; however, most smokers engage minimally with even the best designed websites. The ubiquity of mobile devices and their effectiveness in promoting adherence in other areas of health behaviour change make them a promising tool to address adherence in Internet smoking cessation interventions. Text messaging is used by most adults, and messages can proactively encourage use of a web-based intervention. Text messaging can also be integrated with an Internet intervention to facilitate the use of core Internet intervention components.

METHODS AND ANALYSIS

We identified four aspects of a text message intervention that may enhance its effectiveness in promoting adherence to a web-based smoking cessation programme: personalisation, integration, dynamic tailoring and message intensity. Phase I will use a two-level full factorial design to test the impact of these four experimental features on adherence to a web-based intervention. The primary outcome is a composite metric of adherence that incorporates general utilisation metrics (eg, logins, page views) and specific feature utilisation shown to predict abstinence. Participants will be N=860 adult smokers who register on an established Internet cessation programme and enrol in its text message programme. Phase II will be a two-arm randomised trial to compare the efficacy of the web-based cessation programme alone and in conjunction with the optimised text messaging intervention on 30-day point prevalence abstinence at 9 months. Phase II participants will be N=600 adult smokers who register to use an established Internet cessation programme and enrol in text messaging. Secondary analyses will explore whether adherence mediates the effect of treatment condition on outcome.

ETHICS AND DISSEMINATION

This protocol was approved by Chesapeake IRB. We will disseminate study results through peer-reviewed manuscripts and conference presentations related to the methods and design, outcomes and exploratory analyses.

TRIAL REGISTRATION NUMBER

NCT02585206.

The Cedar Project WelTel mHealth intervention for HIV prevention in young Indigenous people who use illicit drugs: study protocol for a randomized controlled trial

BACKGROUND

Despite successes in preventing and treating HIV, Indigenous people in Canada continue to face disproportionately high rates of HIV infection. Programs that support healing from lifetime trauma, support connection to culture, and reduce drug-related harms are critical to preventing HIV among young Indigenous people who use drugs. The Cedar Project WelTel mHealth intervention proposed here is a structured mobile-phone initiative to connect young Indigenous people who use drugs with Cedar Case Managers in a community-based setting. The intervention consists of a package of supports, including a mobile phone and cellular plan, weekly two-way text messaging, and support from Cedar Case Managers.

METHODS

The Cedar Project WelTel mHealth study is a multi-site Zelen pre-randomized trial to measure the effect of a two-way supportive text-message intervention to reduce HIV vulnerability among young Indigenous people who use illicit drugs in two Canadian cities. The trial is nested within the Cedar Project, an ongoing cohort study addressing HIV and hepatitis C vulnerability among young Indigenous people who use drugs in Vancouver and Prince George, British Columbia. The Cedar Project Partnership, an independent body of Indigenous Elders, leaders, and health/social service experts, governs all aspects of the study. Two hundred participants will be followed over a 16-month period, with HIV propensity score at 6 months as the primary outcome. Secondary outcomes include HIV propensity at 1 year, HIV risk, resilience, psychological distress, access to drug-related services, and connection to culture measured at 6 months and 1 year. Primary analysis is by intention to treat.

DISCUSSION

Culturally safe interventions that address barriers to HIV prevention while supporting the strength of young Indigenous people who use drugs are urgently needed. Despite presenting a tremendous opportunity to connect young, highly transient Indigenous people who use drugs to prevention services, supportive two-way mHealth programs have yet to be tested for HIV prevention in a community-based setting with this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02437123 https://clinicaltrials.gov/show/NCT02437123 (registered 4 May 2015). Protocol version: 24 July 2015.

Use of Technology to Address Substance Use in the Context of HIV: A Systematic Review

Substance users are at elevated risk for HIV. HIV researchers, particularly at the intersection of HIV and substance use, have requested new methods to better understand and address this important area. New technologies, such as social media and mobile applications, are increasingly being used as research tools in studies on HIV and substance use. These technologies have the potential to build on existing recruitment methods, provide new and improved intervention methods, and introduce novel ways of monitoring and predicting new HIV cases. However, little work has been done to review and broadly explore the types of studies being conducted on the use of technologies to address HIV and substance use. This systematic literature review identified studies on this topic between 2005 and 2015. We identified 33 studies on this topic after excluding studies that did not fit inclusion criteria. Studies were either observational (n = 24) or interventional (n = 9), with the majority being pilot studies exploring the feasibility of using these new technologies to study HIV and substance use. We discuss the implications of this work along with limitations and recommendations for future research on this topic.

Recent Evidence for Emerging Digital Technologies to Support Global HIV Engagement in Care

Antiretroviral therapy is a powerful tool to reduce morbidity and mortality for the 35 million people living with HIV globally. However, availability of treatment alone is insufficient to meet new UNAIDS 90-90-90 targets calling for rapid scale-up of engagement in HIV care to end the epidemic in 2030. Digital technology interventions (mHealth, eHealth, and telehealth) are emerging as one approach to support lifelong engagement in HIV care. This review synthesizes recent reviews and primary studies published since January 2014 on digital technology interventions for engagement in HIV care after diagnosis. Technologies for health provide emerging and proven solutions to support achievement of the United Nations targets for the generalized HIV-affected population. Much of the existing evidence addresses antiretroviral therapy (ART) adherence; however, studies have begun to investigate programs to support linkage and retention in care as well as interventions to engage key populations facing extensive barriers to care.

mHealth: An updated systematic review with a focus on HIV/AIDS and tuberculosis long term management using mobile phones

OBJECTIVE

To evaluate the utilization of mobile phone technology for treatment adherence, prevention, education, data collection, monitoring long-term management of HIV/AIDS and TB patients.

METHODS

Articles published in English language from January 2005 until now from PubMed/MEDLINE, EMBASE, Web of Science, WHO databases, and clinical trials were included. Data extraction is based on medication adherence, quality of care, prevention, education, motivation for HIV test, data collection from HIV lab test results and patient monitoring. Articles selected for the analysis cover RCTs and non RCTs related to the use of mobile phones for long-term care and treatment of HIV/AIDS and TB patients.

RESULTS

Out of 90 articles selected for the analysis, a large number of studies, 44 (49%) were conducted in developing countries, 24 (26%) studies from developed countries, 12 (13%) are systematic reviews and 10 (11%) did not mention study location. Forty seven (52.2%) articles focused on treatment, 11 (12.2%) on quality of care, 8 (9%) on prevention, 13 (14.4%) on education, 6 (6.6%) on data collection, and 5 (5.5%) on patient monitoring. Overall, 66 (73%) articles reported positive effects, 21 (23%) were neutral and 3 (4%) reported negative results.

CONCLUSIONS

Mobile phone technology is widely reported to be an effective tool for HIV/AIDS and TB long-term care. It can substantially reduce disease burden on health care systems by rendering more efficient prevention, treatment, education, data collection and management support.

Health care providers' perspectives on a weekly text-messaging intervention to engage HIV-positive persons in care (WelTel BC1)

Though evidence shows that Mobile health (mHealth) interventions can improve adherence and viral load in HIV-positive persons, few have studied the health care providers' (HCP) perspective. We conducted a prospective mixed methods pilot study using the WelTel intervention wherein HIV-positive participants (n = 25) received weekly interactive text messages for 6 months. Text message response rate and topic data were collected to illustrate the HCP experience. The aim of this study is to explore intervention acceptability and feasibility from the HCP perspective through a baseline focus group and end of study interviews with HCP impacted by the intervention. Interview data were thematically coded using the Technology Acceptance Model. HCPs identified that the WelTel intervention engaged patients in building relationships, while organizing and streamlining existing mHealth efforts and dealing with privacy issues. HCPs recognized that although workload would augment initially, intervention benefits were many, and went beyond simply improving HIV viral load.

Exposure to Theory-Driven Text Messages is Associated with HIV Risk Reduction Among Methamphetamine-Using Men Who have Sex with Men

Fifty-two non-treatment-seeking methamphetamine-using men who have sex with men were enrolled in Project Tech Support, an open-label pilot study to evaluate whether exposure to theory-based [social support theory (SST), social cognitive theory (SCT), and health belief model (HBM)] text messages could promote reductions in HIV sexual risk behaviors and/or methamphetamine use. Multivariable analyses revealed that increased relative exposure to HBM or SCT (vs. SST) text messages was associated with significant reductions in the number of HIV serodiscordant unprotected (i.e., without a condom) anal sex partners, engagement in sex for money and/or drugs, and frequency of recent methamphetamine use; additionally, increased relative exposure to HBM (vs. SCT or SST) messages was uniquely associated with reductions in the overall number of non-primary anal sex partners (all p ≤ 0.05, two-tailed). Pilot data demonstrated that text messages based on the principles of HBM and SCT reduced sentinel HIV risk and drug use behaviors in active methamphetamine users.

Distance from care predicts in-hospital mortality in HIV-infected patients with severe sepsis from rural and semi-rural Virginia, USA

There are few data regarding outcomes from severe sepsis for HIV-infected patients living in rural or semi-rural settings. We aim to describe the characteristics and predictors of mortality in HIV-infected patients admitted with severe sepsis to the University of Virginia located in semi-rural Charlottesville, Virginia, USA. We queried the University of Virginia Clinical Data Repository for cases with ICD-9 codes that included: (1) infection, (2) acute organ dysfunction, and (3) HIV infection. We reviewed each case to confirm the presence of HIV infection and severe sepsis. We recorded socio-demographic, clinical, and laboratory data. We used a generalised linear mixed-effects model to assess pre-specified predictors of mortality. We identified 74 cases of severe sepsis in HIV-infected patients admitted to University of Virginia since 2001. The median (IQR) age was 44 (36-49), 32 (43%) were women, and 56 (76%) were from ethnic minorities. The median (IQR) CD4+ T-cell count was 81 (7-281) cells/µL. In-hospital mortality was 20%. When adjusted for severity of illness and respiratory failure, patients who lived >40 miles away from care or had a CD4+ T cell count <50 cells/µL had > four-fold increased risk of death compared to the rest of the study population (AOR = 4.18, 95% CI: 1.09-16.07, p = 0.037; AOR = 4.33, 95% CI: 1.15-16.29, p = 0.03). In HIV-infected patients from rural and semi-rural Virginia with severe sepsis, mortality was increased in those that lived far from University of Virginia or had a low CD4+ T cell counts. Our data suggest that rural HIV-infected patients may have limited access to care, which predisposes them to critical illness and a high associated mortality.

A text messaging intervention to improve retention in care and virologic suppression in a U.S. urban safety-net HIV clinic: study protocol for the Connect4Care (C4C) randomized controlled trial

Background

Few data exist on the use of text messaging as a tool to promote retention in HIV care and virologic suppression at the clinic level in the United States. We describe the protocol for a study designed to investigate whether a text messaging intervention that supports healthy behaviors, encourages consistent engagement with care, and promotes antiretroviral persistence can improve retention in care and virologic suppression among patients in an urban safety-net HIV clinic in San Francisco.

Methods/Design

Connect4Care (C4C) is a single-site, randomized year-long study of text message appointment reminders vs. text message appointment reminders plus thrice-weekly supportive, informational, and motivational text messages. Eligible consenting patients are allocated 1:1 to the two arms within strata defined by HIV diagnosis within the past 12 months (i.e. “newly diagnosed”) vs. earlier. Study participants must receive primary care at the San Francisco General Hospital HIV clinic, speak English, possess a cell phone and be willing to send/receive up to 25 text messages per month, a have viral load >200 copies/μL, and be either new to the clinic or have a history of poor retention. The primary efficacy outcome is virologic suppression at 12 months and the key secondary outcome, which will also be examined as a mediator of the primary outcome, is retention in HIV care, as operationalized by kept and missed primary care visits. Process outcomes include text message response rate and percent of time in study without cell phone service. Generalized estimating equation log-binomial models will be used for intent to treat, per protocol, and mediation analyses. An assessment of the cost and cost-effectiveness of the intervention is planned along with a qualitative evaluation of the intervention.

Discussion

Findings from this study will provide valuable information about the use of behavioral-theory based text messaging to promote retention in HIV care and virologic suppression, further elucidate the challenges of using texting technology with marginalized urban populations, and help guide the development of new mobile health strategies to improve HIV care cascade outcomes.

Trial registration

NCT01917994

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0718-6) contains supplementary material, which is available to authorized users.

Novel interventions for HIV self-management in African American women: a systematic review of mHealth interventions

The purpose of this systematic review was to assess the quality of interventions using mobile health (mHealth) technology being developed for and trialed with HIV-infected African American (AA) women. We aimed to assess rigor and to ascertain if these interventions have been expanded to include the broad domain of self-management. After an extensive search using the PRISMA approach and reviewing 450 records (411 published studies and 39 ongoing trials at clinicaltrials.gov), we found little completed research that tested mHealth HIV self-management interventions for AA women. At clinicaltrials.gov, we found several mHealth HIV intervention studies designed for women in general, forecasting a promising future. However, most studies were exploratory in nature and focused on a single narrow outcome, such as medication adherence. Given that cultural adaptation is the key to successfully implementing any effective self-management intervention, culturally relevant, gender-specific mHealth interventions focusing on HIV-infected AA women are warranted for the future.